Operative Technique and Lessons Learned From Surgical Implantation of the NeuroPace Responsive Neurostimulation® System in 57 Consecutive Patients

2020 ◽  
Author(s):  
Max O Krucoff ◽  
Thomas A Wozny ◽  
Anthony T Lee ◽  
Vikram R Rao ◽  
Edward F Chang
Keyword(s):  
Operative Technique ◽  
Focal Epilepsy ◽  
Intraoperative Imaging ◽  
Case Series ◽  
Lessons Learned ◽  
Seizure Freedom ◽  
Operative Techniques ◽  
Surgical Positioning ◽  
Intracerebral Hemorrhages

Abstract BACKGROUND The Responsive Neurostimulation (RNS)® System (NeuroPace, Inc) is an implantable device designed to improve seizure control in patients with medically refractory focal epilepsy. Because it is relatively new, surgical pearls and operative techniques optimized from experience beyond a small case series have yet to be described. OBJECTIVE To provide a detailed description of our operative technique and surgical pearls learned from implantation of the RNS System in 57 patients at our institution. We describe our method for frame-based placement of amygdalo-hippocampal depth leads, open implantation of cortical strip leads, and open installation of the neurostimulator. METHODS We outline considerations for patient selection, preoperative planning, surgical positioning, incision planning, stereotactic depth lead implantation, cortical strip lead implantation, craniotomy for neurostimulator implantation, device testing, closure, and intraoperative imaging. RESULTS The median reduction in clinical seizure frequency was 60% (standard deviation 63.1) with 27% of patients achieving seizure freedom at last follow up (median 23.1 mo). No infections, intracerebral hemorrhages, or lead migrations were encountered. Two patients experienced lead fractures, and four lead exchanges have been performed. CONCLUSION The techniques set forth here will help with the safe and efficient implantation of these new devices.

Stereoelectroencephalography in Children and Adolescents With Difficult-to-Localize Refractory Focal Epilepsy

Neurosurgery ◽  
2014 ◽  
Vol 75 (3) ◽  
pp. 258-268 ◽  
Author(s):  
Jorge Gonzalez-Martinez ◽  
Jeffrey Mullin ◽  
Juan Bulacio ◽  
Ajay Gupta ◽  
Rei Enatsu ◽  
...  
Keyword(s):  
Children And Adolescents ◽  
Pediatric Patients ◽  
Focal Epilepsy ◽  
Early Experience ◽  
Morbidity Rate ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Eloquent Cortex

Abstract BACKGROUND: Although stereoelectroencephalography (SEEG) has been shown to be a valuable tool for preoperative decision making in focal epilepsy, there are few reports addressing the utility and safety of SEEG methodology applied to children and adolescents. OBJECTIVE: To present the results of our early experience using SEEG in pediatric patients with difficult-to-localize epilepsy who were not considered candidates for subdural grid evaluation. METHODS: Thirty children and adolescents with the diagnosis of medically refractory focal epilepsy (not considered ideal candidates for subdural grids and strip placement) underwent SEEG implantation. Demographics, electrophysiological localization of the hypothetical epileptogenic zone, complications, and seizure outcome after resections were analyzed. RESULTS: Eighteen patients (60%) underwent resections after SEEG implantations. In patients who did not undergo resections (12 patients), reasons included failure to localize the epileptogenic zone (4 patients); multifocal epileptogenic zone (4 patients); epileptogenic zone located in eloquent cortex, preventing resection (3 patients); and improvement in seizures after the implantation (1 patient). In patients who subsequently underwent resections, 10 patients (55.5%) were seizure free (Engel class I) and 5 patients (27.7%) experienced seizure improvement (Engel class II or III) at the end of the follow-up period (mean, 25.9 months; range, 12 to 47 months). The complication rate in SEEG implantations was 3%. CONCLUSION: The SEEG methodology is safe and should be considered in children/adolescents with difficult-to-localize epilepsy. When applied to highly complex and difficult-to-localize pediatric patients, SEEG may provide an additional opportunity for seizure freedom in association with a low morbidity rate.

Levetiracetam monotherapy for treatment of structural epilepsy in dogs: 19 cases (2010–2015)

2017 ◽  
Vol 181 (15) ◽  
pp. 401-401 ◽  
Author(s):  
Darren Kelly ◽  
Francesca Raimondi ◽  
Nadia Shihab
Keyword(s):  
Side Effects ◽  
Seizure Control ◽  
Case Series ◽  
Poor Response ◽  
Response To Treatment ◽  
Seizure Freedom ◽  
Retrospective Case ◽  
Cluster Seizures ◽  
Structural Epilepsy

To evaluate the efficacy and tolerability of levetiracetam monotherapy in dogs with structural epilepsy. Retrospective case series. Nineteen client-owned dogs with structural epilepsy. Seizure frequencies after initiation of treatment were used to evaluate the efficacy of levetiracetam monotherapy. Seizure control was considered good if no seizures occurred within three months of starting treatment or poor if seizures returned within one month of starting treatment. Tolerability was evaluated by considering the occurrence and severity of any reported side effects. Ten of the 19 dogs were considered to have a good response to treatment with 7 achieving complete seizure freedom. Nine dogs were considered to have poor response to treatment. There was a statistically significant reduction in the percentage of patients experiencing cluster seizures from 68.4% to 15.8% (p=0.002). Side effects were noted in 8 of the 19 dogs but were considered mild in all cases. Follow-up times ranged from 12 days to 426 days. When used in conjunction with other appropriate therapies, levetiracetam may be an efficacious option for monotherapy in dogs with structural epilepsy. Its tolerability makes it a suitable option for use in a wide variety of patients.

New interinstitutional, multimodal presurgical evaluation protocol associated with improved seizure freedom for poorly defined cases of focal epilepsy in children

2021 ◽  
pp. 1-9
Author(s):  
Solon Schur ◽  
Jeremy T. Moreau ◽  
Hui Ming Khoo ◽  
Andreas Koupparis ◽  
Elisabeth Simard Tremblay ◽  
...  
Keyword(s):  
Focal Epilepsy ◽  
Seizure Freedom ◽  
Presurgical Evaluation ◽  
3T Mri ◽  
Evaluation Strategy ◽  
New Strategy ◽  
The Difference ◽  
Highly Correlated ◽  
Intracranial Recording

OBJECTIVE In an attempt to improve postsurgical seizure outcomes for poorly defined cases (PDCs) of pediatric focal epilepsy (i.e., those that are not visible or well defined on 3T MRI), the authors modified their presurgical evaluation strategy. Instead of relying on concordance between video-electroencephalography and 3T MRI and using functional imaging and intracranial recording in select cases, the authors systematically used a multimodal, 3-tiered investigation protocol that also involved new collaborations between their hospital, the Montreal Children’s Hospital, and the Montreal Neurological Institute. In this study, the authors examined how their new strategy has impacted postsurgical outcomes. They hypothesized that it would improve postsurgical seizure outcomes, with the added benefit of identifying a subset of tests contributing the most. METHODS Chart review was performed for children with PDCs who underwent resection following the new strategy (i.e., new protocol [NP]), and for the same number who underwent treatment previously (i.e., preprotocol [PP]); ≥ 1-year follow-up was required for inclusion. Well-defined, multifocal, and diffuse hemispheric cases were excluded. Preoperative demographics and clinical characteristics, resection volumes, and pathology, as well as seizure outcomes (Engel class Ia vs > Ia) at 1 year postsurgery and last follow-up were reviewed. RESULTS Twenty-two consecutive NP patients were compared with 22 PP patients. There was no difference between the two groups for resection volumes, pathology, or preoperative characteristics, except that the NP group underwent more presurgical evaluation tests (p < 0.001). At 1 year postsurgery, 20 of 22 NP patients and 10 of 22 PP patients were seizure free (OR 11.81, 95% CI 2.00–69.68; p = 0.006). Magnetoencephalography and PET/MRI were associated with improved postsurgical seizure outcomes, but both were highly correlated with the protocol group (i.e., independent test effects could not be demonstrated). CONCLUSIONS A new presurgical evaluation strategy for children with PDCs of focal epilepsy led to improved postsurgical seizure freedom. No individual presurgical evaluation test was independently associated with improved outcome, suggesting that it may be the combined systematic protocol and new interinstitutional collaborations that makes the difference rather than any individual test.

Insular epilepsy surgery: lessons learned from institutional review and patient-level meta-analysis

2021 ◽  
pp. 1-13
Author(s):  
Panagiotis Kerezoudis ◽  
Rohin Singh ◽  
Anshit Goyal ◽  
Gregory A. Worrell ◽  
W. Richard Marsh ◽  
...  
Keyword(s):  
Epilepsy Surgery ◽  
Meta Analysis ◽  
Univariate Analysis ◽  
Brain Regions ◽  
Lessons Learned ◽  
Postoperative Outcomes ◽  
Seizure Freedom ◽  
Low Grade ◽  
Current Series

OBJECTIVE Insular lobe epilepsy is a challenging condition to diagnose and treat. Due to anatomical intricacy and proximity to eloquent brain regions, resection of epileptic foci in that region can be associated with significant postoperative morbidity. The aim of this study was to review available evidence on postoperative outcomes following insular epilepsy surgery. METHODS A comprehensive literature search (PubMed/MEDLINE, Scopus, Cochrane) was conducted for studies investigating the postoperative outcomes for seizures originating in the insula. Seizure freedom at last follow-up (at least 12 months) comprised the primary endpoint. The authors also present their institutional experience with 8 patients (4 pediatric, 4 adult). RESULTS A total of 19 studies with 204 cases (90 pediatric, 114 adult) were identified. The median age at surgery was 23 years, and 48% were males. The median epilepsy duration was 8 years, and 17% of patients had undergone prior epilepsy surgery. Epilepsy was lesional in 67%. The most common approach was transsylvian (60%). The most commonly resected area was the anterior insular region (n = 42, 21%), whereas radical insulectomy was performed in 13% of cases (n = 27). The most common pathology was cortical dysplasia (n = 68, 51%), followed by low-grade neoplasm (n = 16, 12%). In the literature, seizure freedom was noted in 60% of pediatric and 69% of adult patients at a median follow-up of 29 months (75% and 50%, respectively, in the current series). A neurological deficit occurred in 43% of cases (10% permanent), with extremity paresis comprising the most common deficit (n = 35, 21%), followed by facial paresis (n = 32, 19%). Language deficits were more common in left-sided approaches (24% vs 2%, p < 0.001). Univariate analysis for seizure freedom revealed a significantly higher proportion of patients with lesional epilepsy among those with at least 12 months of follow-up (77% vs 59%, p = 0.032). CONCLUSIONS These findings may serve as a benchmark when tailoring decision-making for insular epilepsy, and may assist surgeons in their preoperative discussions with patients. Although seizure freedom rates are quite high with insular epilepsy treatment, the associated morbidity needs to be weighed against the potential for seizure freedom.

scholarly journals The use of simultaneous stereo-electroencephalography and magnetoencephalography in localising the epileptogenic focus in refractory focal epilepsy

2021 ◽  
Author(s):  
Umesh Vivekananda ◽  
Chunyan Cao ◽  
Wei Liu ◽  
Jing Zhang ◽  
Fergus Rugg-Gunn ◽  
...  
Keyword(s):  
Focal Epilepsy ◽  
Epileptiform Activity ◽  
Case Series ◽  
Seizure Freedom ◽  
Interictal Spikes ◽  
Significant Difference ◽  
Surgical Evaluation ◽  
Deep Source ◽  
Deep Sources ◽  
Epileptogenic Foci

Abstract Both magnetoencephalography and stereo-electroencephalography are used in presurgical epilepsy assessment, with contrasting advantages and limitations. It is not known whether simultaneous stereo-electroencephalography-magnetoencephalography recording confers an advantage over both individual modalities, in particular whether magnetoencephalography can provide spatial context to epileptiform activity seen on stereo-electroencephalography. 24 adult and paediatric patients who underwent stereo-electroencephalography study for pre-surgical evaluation of drug-resistant focal epilepsy, were recorded using simultaneous stereo-electroencephalography-magnetoencephalography, of which 14 had abnormal interictal activity during recording. The 14 patients were divided into two groups; those with detected superficial (n = 7) and deep (n = 7) brain interictal activity. Interictal spikes were independently identified in stereo-electroencephalography and magnetoencephalography. Magnetoencephalography dipoles were derived using a distributed inverse method. There was no significant difference between stereo-electroencephalography and magnetoencephalography in detecting superficial spikes (p = 0.135) and stereo-electroencephalography was significantly better at detecting deep spikes (p = 0.002). Mean distance across patients between stereo-electroencephalography channel with highest average spike amplitude and magnetoencephalography dipole was 20.7+/- 4.4 mm. for superficial sources, and 17.8 +/- 3.7 mm. for deep sources, even though for some of the latter (n = 4) no magnetoencephalography spikes were detected and magnetoencephalography dipole was fitted to a stereo-electroencephalography interictal activity triggered average. Removal of magnetoencephalography dipole was associated with 1 year seizure freedom in 6/7 patients with superficial source, and 5/6 patients with deep source. Although stereo-electroencephalography has greater sensitivity in identifying interictal activity from deeper sources, a magnetoencephalography source can be localised using stereo-electroencephalography information, thereby providing useful whole brain context to stereo-electroencephalography and potential role in epilepsy surgery planning.In the largest case series to date, Vivekananda et al. perform simultaneous magnetoencephalography and stereo-electroencephalography in refractory focal epilepsy patients. They demonstrate that for deep brain epileptogenic foci, magnetoencephalography dipoles could be derived from average stereo-electroencephalography data, thereby overcoming a traditional limitation of magnetoencephalography of reduced sensitivity for deep sources.

scholarly journals Outcome of lesional epilepsy surgery

2019 ◽  
Vol 9 (4) ◽  
pp. 286-295 ◽  
Author(s):  
Jafar Mehvari Habibabadi ◽  
Houshang Moein ◽  
Reza Basiratnia ◽  
Shervin Badihian ◽  
Bagher Zaki ◽  
...  
Keyword(s):  
Epilepsy Surgery ◽  
Focal Epilepsy ◽  
Postoperative Outcome ◽  
Resource Poor Setting ◽  
Seizure Freedom ◽  
Mesial Temporal Sclerosis ◽  
Prospective Longitudinal Study ◽  
Mortality And Morbidity ◽  
Prospective Longitudinal

BackgroundWe investigated the utility of epilepsy surgery and postoperative outcome in patients with lesional epilepsy in Iran, a relatively resource-poor setting.MethodsThis prospective longitudinal study was conducted during 2007–2017 in Kashani Comprehensive Epilepsy Center, Isfahan, Iran. Patients with a diagnosis of intractable focal epilepsy, with MRI lesions, who underwent epilepsy surgery and were followed up ≥ 24 months, were included and evaluated for postoperative outcome.ResultsA total of 214 patients, with a mean age of 26.90 ± 9.82 years (59.8% men) were studied. Complex partial seizure was the most common type of seizure (85.9%), and 54.2% of the cases had auras. Temporal lobe lesions (75.2%) and mesial temporal sclerosis (48.1%) were the most frequent etiologies. With a mean follow-up of 62.17 ± 19.33 months, 81.8% of patients became seizure-free postoperatively. Anticonvulsants were reduced in 86% of the cases and discontinued in 40.7%. In keeping with previous studies, we found that seizure freedom rates were lower among patients with longer follow-up periods.ConclusionsWe found high rates of seizure freedom after surgery in lesional epilepsy patients despite limited facilities and infrastructure; antiepileptic medications were successfully tapered in almost half of the patients. Considering the favorable outcome of epilepsy surgery in our series, we believe that it is a major treatment option, even in less resource-intensive settings, and should be encouraged. Strategies to allow larger scale utility of epilepsy surgery in such settings in the developing world and dissemination of such knowledge may be considered an urgent clinical need, given the established mortality and morbidity in refractory epilepsy.

Outcomes after hemispherectomy in adult patients with intractable epilepsy: institutional experience and systematic review of the literature

2018 ◽  
Vol 128 (3) ◽  
pp. 853-861 ◽  
Author(s):  
Courtney M. Schusse ◽  
Kris Smith ◽  
Cornelia Drees
Keyword(s):  
Neuropsychological Testing ◽  
Case Series ◽  
Intractable Epilepsy ◽  
Adult Patients ◽  
Morbidity Rate ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Surgical Tool ◽  
Drug Resistant Epilepsy

OBJECTIVEHemispherectomy is a surgical technique that is established as a standard treatment in appropriately selected patients with drug-resistant epilepsy. It has proven to be successful in pediatric patients with unilateral hemispheric lesions but is underutilized in adults. This study retrospectively evaluated the clinical outcomes after hemispherectomy in adult patients with refractory epilepsy.METHODSThis study examined 6 cases of hemispherectomy in adult patients at Barrow Neurological Institute. In addition, all case series of hemispherectomy in adult patients were identified through a literature review using MEDLINE and PubMed. Case series of patients older than 18 years were included; reports of patients without clear follow-up duration or method of validated seizure outcome quantification were excluded. Seizure outcome was based on the Engel classification.RESULTSA total of 90 cases of adult hemispherectomy were identified, including 6 newly added by Barrow Neurological Institute. Sixty-five patients underwent functional hemispherectomy; 25 patients had anatomical hemispherectomy. Length of follow-up ranged from 9 to 456 months. Seizure freedom was achieved in 80% of patients. The overall morbidity rate was low, with 9 patients (10%) having new or additional postoperative speech or language dysfunction, and 19 patients (21%) reporting some worsening of hemiparesis. No patients lost ambulatory or significant functional ability, and 2 patients had objective ambulatory improvement. Among the 41 patients who underwent additional formal neuropsychological testing postoperatively, overall stability or improvement was seen.CONCLUSIONSHemispherectomy is a valuable surgical tool for properly selected adult patients with pre-existing hemiparesis and intractable epilepsy. In published cases, as well as in this series, the procedure has overall been well tolerated without significant morbidity, and the majority of patients have been rendered free of seizures.

Laparoscopic Gastric Bypass at a Large Academic Medical Center: Lessons Learned from the First 1000 Cases

2008 ◽  
Vol 74 (10) ◽  
pp. 962-966 ◽  
Author(s):  
Talar Tejirian ◽  
Candice Jensen ◽  
Catherine Lewis ◽  
Erik Dutson ◽  
Amir Mehran
Keyword(s):  
Gastric Bypass ◽  
Weight Regain ◽  
Practice Patterns ◽  
Academic Medical Center ◽  
Gastric Pouch ◽  
Lessons Learned ◽  
Operative Techniques ◽  
Selective Approach

Bariatric surgery is an effective and durable treatment for morbid obesity in properly selected patients. Surgical outcomes and patient management methods should routinely be reviewed to improve patient care and maintain long-term effectiveness of the bariatric operation. Over a 5-year period, 1096 laparoscopic Roux-en-Y gastric bypass operations were performed at our institution. A comprehensive prospective database was maintained, which included data for comorbidities, operative techniques, perioperative management, complications, and follow up. Many practice patterns such as the omission of routine preoperative sleep apnea testing and biliary ultrasounds remained constant and were validated by the outcomes measured. Several changes, however, were implemented based on outcomes analyses, including antecolic placement of the roux limb, a pars flaccida approach to the creation of the gastric pouch, longer alimentary limbs in superobese patients, and a selective approach to postoperative upper gastrointestinal imaging. Postoperative weight regain and inability to maintain long-term follow up in a significant per cent of patients were two identified and ongoing problems. Maintenance of a bariatric patient database is essential with its routine review resulting in changes to practice patterns and operative techniques. An effective method for long-term patient follow up remains elusive and may contribute to postoperative weight regain in some patients.

Rates and predictors of long-term seizure freedom after frontal lobe epilepsy surgery: a systematic review and meta-analysis

2012 ◽  
Vol 116 (5) ◽  
pp. 1042-1048 ◽  
Author(s):  
Dario J. Englot ◽  
Doris D. Wang ◽  
John D. Rolston ◽  
Tina T. Shih ◽  
Edward F. Chang
Keyword(s):  
Systematic Review ◽  
Frontal Lobe ◽  
Focal Epilepsy ◽  
Meta Analysis ◽  
Epileptic Focus ◽  
Epilepsy Syndrome ◽  
Frontal Lobe Epilepsy ◽  
Seizure Freedom

Object Frontal lobe epilepsy (FLE) is the second-most common focal epilepsy syndrome, and seizures are medically refractory in many patients. Although various studies have examined rates and predictors of seizure freedom after resection for FLE, there is significant variability in their results due to patient diversity, and inadequate follow-up may lead to an overestimation of long-term seizure freedom. Methods In this paper the authors report a systematic review and meta-analysis of long-term seizure outcomes and predictors of response after resection for intractable FLE. Only studies of at least 10 patients examining seizure freedom after FLE surgery with postoperative follow-up duration of at least 48 months were included. Results Across 1199 patients in 21 studies, the overall rate of postoperative seizure freedom (Engel Class I outcome) was 45.1%. No trend in seizure outcomes across all studies was observed over time. Significant predictors of long-term seizure freedom included lesional epilepsy origin (relative risk [RR] 1.67, 95% CI 1.36–28.6), abnormal preoperative MRI (RR 1.64, 95% CI 1.32–2.08), and localized frontal resection versus more extensive lobectomy with or without an extrafrontal component (RR 1.71, 95% CI 1.26–2.43). Within lesional FLE cases, gross-total resection led to significantly improved outcome versus subtotal lesionectomy (RR 1.99, 95% CI 1.47–2.84). Conclusions These findings suggest that FLE patients with a focal and identifiable lesion are more likely to achieve seizure freedom than those with a more poorly defined epileptic focus. While seizure freedom can be achieved in the surgical treatment of medically refractory FLE, these findings illustrate the compelling need for improved noninvasive and invasive localization techniques in FLE.

scholarly journals Seizure Freedom in Temporal Plus Epilepsy Surgery Following Stereo-Electroencephalography

2020 ◽  
Vol 47 (3) ◽  
pp. 374-381
Author(s):  
Juan S. Bottan ◽  
Ana Suller Marti ◽  
Andrew G. Parrent ◽  
Keith W. MacDougall ◽  
Richard S. McLachlan ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Epilepsy Surgery ◽  
Right Hemisphere ◽  
Case Series ◽  
Temporal Lobectomy ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Small Case Series ◽  
Adjacent Structures

ABSTRACT:Background:“Temporal plus” epilepsy (TPE) is a term that is used when the epileptogenic zone (EZ) extends beyond the boundaries of the temporal lobe. Stereotactic electroencephalography (SEEG) has been essential to identify additional EZs in adjacent structures that might be part of the temporal lobe/limbic network.Objective:We present a small case series of temporal plus cases successfully identified by SEEG who were seizure-free after resective surgery.Methods:We conducted a retrospective analysis of 156 patients who underwent SEEG in 5 years. Six cases had TPE and underwent anterior temporal lobectomy (ATL) with additional extra-temporal resections.Results:Five cases had a focus on the right hemisphere and one on the left. Three cases were non-lesional and three were lesional. Mean follow-up time since surgery was 2.9 years (SD ± 1.8). Three patients had subdural electrodes investigation prior or in addition to SEEG. All patients underwent standard ATL and additional extra-temporal resections during the same procedure or at a later date. All patients were seizure-free at their last follow-up appointment (Engel Ia = 3; Engel Ib = 2; Engel Ic = 1). Pathology was nonspecific/gliosis for all six cases.Conclusion:TPE might explain some of the failures in temporal lobe epilepsy surgery. We present a small case series of six patients in whom SEEG successfully identified this phenomenon and surgery proved effective.

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